EMCrit – A Debate on the Use of Cognitive Decision Aids for Resuscitation and why Twitter is absolute, utter Crap

After the initial publication of the Resus Crisis Manual, a thread started on twitter

The Tweets that Inspired the Debate

Sorry, but if you need a "how to do it" bullet list to handle resus pts your no1 priority should be to call someone who does not need that list! #HQCC no excuses, no exceptions! https://t.co/05rj8wtdBk

.The paradox is that a ”resuscitationist” (by def trained & prepped to handle resuspts?) does not need literature like the exmple StEp ch. & someone who needs such lists risks being lured into situations they shouldn’t handle alone (in places where these pts predictably appear!)

Joacim Linde

Consultant Anesthesia. Critical Care/EMS/PHCC

Medical Director, County Ambulance Consult Health & Social Care

Inspectorate Director Swedish P-EMS/PHCC course

My Response to the Tweets

Joacim

This debate seemed kind of muddled on twitter, which I imagine is due to space constraints.
As I understand things, a fellow flight doc make a positive comment about the book and your response was to state that anyone who needs the RCM is someone who should not be taking care of resus patients and they should promptly call someone who doesn’t need the book in order to take care of these patients.

Further, can we accept as a given that a book such as this (or an idealized version thereof if this one happens to stink) can be incredibly useful for trainees not actually engaged in a resuscitation (i.e. during their study time)

I assume we agree on that one, so the real crux of the question is does an idealized version of a book such as this, which i will refer to as a resus Quick Reference Handbook (rQRH) have value in the midst of an actual resus.

My argument is that is does and I will make my argument from 3 points in time:

You have advanced notification of a patient in a Resus Setting

Most of the protocols in this book are infrequently encountered emergencies. Every resus doctor should know the bold face actions by heart (the entire left side are only bold face actions–used the same way as in aviation) [edit.-if you want to understand the boldface, listen to Novak's lecture] and easily be able to accomplish excellent care if they had no such book to review ahead of the emergency. Reviewing the right hand side for drug doses, etc. for something a resus doc may see once every 2 years doesn’t deserve the opprobrium you seem to assign the action

You have stabilized the Resus patient

Reviewing both the boldface and non-boldface actions as a cross-check seems very reasonable for emergencies you trained on, but see infrequently. Again it would seem unfair to malign a doc who felt reassured by this. Further this is precisely what is supposed to occur for all boldfaceactions in aviation once the crisis has been stabilized.

During the Critical Portions of the Resus Itself

I agree with you that any resuscitationist should have no use for a rQRH during the resus.

But there are a host of other providers who might. The one that springs to mind immediately is the community ED doc that may see any of these emergencies once every ten years. You can make the argument all you want that someone that only sees these issues once a decade shouldn’t take care of them but that is a pipedream. These are usually the only docs in these hospitals for many hours of the day and they are definitely going to transfer these pts to a bigger hospital, but that doesn’t account for the hour to hours that they need to care for these patients. If you accept that this situation exists, would you rather they had a rQRH or not. I would rather it was available.

I can think of a bunch of other cases where it would be great to have a resus-only doctor caring for a patient, but that just is not possible for a set period of time in which the pt can get much worse without proper care.

But the argument you seem to be making in the thread that sparked this is that there is a group of doctors that would ordinarily get help, but now armed with the rQRH will suddenly feel emboldened to not call for help/not transfer a sick patient. This is what I referred to as a straw man. I don’t see how this is anything but a speculative hypothetical. Who is this group? I can’t picture them in the States–perhaps your practice pattern is different. Nobody I can imagine would be in a position to take care of these patients in a situation where a rQRH would change whether they called for help vs. not. The only one I can come close to imagining is the Aussie ED registrars where there is no consultant in-house night coverage. But in those cases, the rQRH can be incredibly helpful while they are waiting for their consultant to arrive.

But even in these cases, I can’t see anyone running an actual resus in real time with this book open in front of them, that seems similar to the apocryphal stories of operations being performed with a nurse reading out the steps of the operation. That may have occurred but probably not in our generation.

My entire job is resus–that is all I do every day of the year. I think you are in a similar gig. I also spent 4 years editing this book. If anyone has the training and experience not to need this book, I think it is me. And yet I will happily look it over pre or post uncommon emergencies b/c I am not perfect, my cognitive faculties are often stressed by the 12 other critically ill patients I am caring for and the chaos that is my unit. If you truly think that makes me someone who shouldn’t be practicing resus, by all means tell me that.

So do I need this book? It depends on what you mean by need. Can I resus any situation in the book without the book–yes. Can I do it as well EVERY TIME in every circumstance regardless of what else is going on, probably not. That is my definition of need.

Crisis has a couple of different definitions in English. You have taken umbrage at any emergency being described as a crisis by a resus professional–so it seems you are using the definition of a time of intense difficulty and perhaps this is the source of our disagreement. The crisis of the RCM is defined by a time of critical decisions.

Joacim Responds

Scott,

Your arguments are well phrased, and there are certainly many ways checklists are beneficial. Having said that – I still believe the type of manual (as opposed to short checklists) we are discussing can create a problem, and I wish to elaborate a bit on this.

I would state that – with or without a manual – true quality of care in resuscitation is impossible unless the provider has advanced training combined with continuous exposure to these patients.

In certain contexts, such as South Africa (or perhaps Baltimore?), continuous exposure is perhaps not an issue. Many other regions, such as Scandinavia, have the opposite “problem” – true traumatic (and medical) emergencies are scarce, and it´s actually difficult for providers to get training, and uphold experience.

Our medical tradition and way off solving this has been to limit the number of providers, thus increasing exposure for the individual. Generally this philosophy is not controversial – for instance “General Surgery” is a rare phenomenon. In all areas with adequate resources we concentrate patients into places like – Liver Transplant Centres, Paediatric Surgery Units, and Trauma Centres where we strive to concentrate cases, thus increasing exposure.
The demand for quality is non-negotiable in a modern world context. One would hardly be trusted to operate on a ruptured AAA or do the PCI of a STEMI alone without documented and upheld expertise in one´s specialty.
Of course, handling resus with maximum available proficiency is just as necessary!

In Scandinavia the Anaesthesia/ICU doctors are the “resuscitationists”, a mandate received by dedicated training and continuous exposure in the ICU and operating theatre, as well as traditionally for all resus cases – inhospital answering resus calls in the ED and in regular wards and prehospitally by responding by ambulance helicopters and rapid response cars to patients in need of prehospital intensive care. This is our version of “bringing upstairs care downstairs (and even out the doors)”. In this way, we guarantee that also the resus patient gets medical care of adequate quality wherever they may fall sick.

In extreme rural areas, or in third world contexts, it may not be realistic to have this type of team continuously available. There are situations where circumstances are such that an inexperienced doctor really NEEDS to immediately assess and treat truly failing vital signs. Different well known concept courses originally catered for these needs. It is my belief that a manual as the one discussed could help in these situations. However these types of aid often represent a minimum acceptable standard and a manual aimed at these situations will have to responsibly handle the level of care that the user of the manual safely can reach.

Our opinion is that this situation is very rare, and virtually NEVER the case in rural Scandinavia. And in our type of western context it is- in our opinion- always a better idea to call for help than to try to solve the problem oneself. Even with the best reference manual in the world.

Can the specialized resuscitationist be helped by, a quick reference manual? The easy and short answer is, of course he can.
Like yourself I will however answer also by asking myself that question, will I read it and would I really need it?
It will undoubtedly be a popular book and part of my responsibility is to be updated. Therefore, I have read it. (and naturally after 20+ years in hospital and prehospital CC I strongly disagree with lots of things in it 🙂 that however is not the point)

The problems with writing a book in a format where the reader expects ready to follow “recipes” is that as soon as you put down any advice in writing you lose the individual flexibility and the ability to, in your advice, cater for the inter-individual differences that make up for most of the challenges to reach high quality resuscitation.

Ultimately, the “tailored treatment” that is one of the reasons I'm there, risks being lost.
I would not bring the book to resus.
Most of all I would constantly be worried that my junior colleagues would bring the book instead of preparing in advance and most importantly, instead of calling me!

Why?

I'll let you in on a little secret Scott. All through my studies, both to a M.Sc. and civil engineer degree in computer science and later to an M.D. I wrote “cheat sheets” for the exams.. Luckily the sweaty small notes stayed in my pocket and I never had to use them. You see, by the time I meticulously had written, processed and condensed even the most difficult mathematical theorem on a small piece of paper I not only knew it by heart but actually understood it.
Don’t take me wrong, I’m not calling a manual “cheating” but I do think that if I would have bought these notes ready-made the risk of me having to use them would have increased tremendously. With such a strategy I also know I would have been a much worse doc.

Knowledge is a lot about the process where you acquire it and understanding something beats knowing it by heart every day of the week and even just knowing something by heart beats reading it from a list by a mile. Also in resus!
I want my junior colleagues to understand what they should do and also why.
Being by their side during resus gives me the opportunity to tutor and teach them as best I can.

But the real problem (at least in Scandinavia) is this:

Most patients are not “champagne and glamour”. They are Hip Fractures and Urinary Tract Infections, they are Psychiatric and Social Problems, Old Age and Loneliness. It is not always thrilling and exciting, it is frequently unrewarding. This is the reality for most doctors. Particularly the work of the ER doctors, who face the unfiltered problems of our society and the bulk of patients, is unappreciated. Few patients need resus, it´s very different from TV series like “ER” and “Grey´s Anatomy” that some of them watched before starting medical school. And – though clearly one of the prime medical advances of the last decades, spreading knowledge like never before – the FOAM community and the glamourous SMACC conference also focuses on Resus to a very high degree.

I believe you have described a bit of this in your SMACC talk “ER is a failed paradigm”. Though that of course was a deliberately provocative title, that neither you nor I believe in, there are aspects of truth to this. It is a real problem for many, particularly young, ER doctors in Sweden where the specialty is new, and in the process of “finding its place” in the existing health care structure. What new ER doctor doesn´t listen to Emcrit, and dream of doing just what Scott Weingart does?

I therefore understand, and truly sympathize with, doctors trying to do as much of the resus as possible themselves, and using a quick reference manual to solve the issues they are so rarely exposed to is a tempting quick fix. But I also truly feel it is not in the best interest of the patients in our context. I believe there is a real danger that young colleagues are being lured into situations they are not ready to handle by themselves.

Instead, the actual work in the ER must be more appreciated, such as it is. This is a responsibility for the society as a whole – news reporters, politicians and hospital management. It is also a responsibility for the FOAM community and even the SMACC conference.

At least in our part of the world high quality resuscitation ultimately and undisputedly depends on concentrating the patients on specifically dedicated “resuscitation specialists” (in Scandinavia presently Anesthesia and intensive care), defined by their competence rather than by their ambitions. To comply with health legislation here these must be able to uphold ICU quality to their resus and the training of these must include regular and frequent exposure to patients with failing vital signs, good environment specific training and theoretical studies that promote understanding of not only “how to” but just as importantly “why”.
Such a specialty will be able to uphold high quality of care in the resus situation wherever it may be – inhospital or out of hospital.
Finally, a manual like the one discussed would for these resuscitationists be one of many tools that, when used wisely, certainly could help promote quality of care.

/Joacim

My Thoughts after reading Joacim's Reply

Twitter is Crap!

The thought foremost in my mind is that twitter is perhaps the worst thing that has ever happened to discourse. I read the comments on twitter and think what is wrong with this person, they are obviously deluded or are they deliberately trolling. Then I read the actual thoughts behind the 280 characters and think that not only do I almost entirely agree with this person, but based on words alone there is a kindred soul out there. How can those two impressions be diametrically opposed–simple, twitter is garbage. Twitter breeds discontent and misunderstanding; I would go so far as to say it is built to do so.

Now, clearly I should have listened to the miniature Jenny Rudolph sitting on my shoulder. When I read Joacim's twitter comments and said to myself, “What the F&*k,” I should have immediately asked instead, “What's their Frame?” The problem is I would have had no idea what Joacim's frame was. Luckily he has enough intellectual fortitude to want to spend the time to actually craft his thoughts in longform–if this was a requirement for every snarky comment on twitter, how many tweets would remain?

Where Joacim Changed My Mind

Now that I have gotten to ruminate on Joacim's comments I can see how we can both be right and why I initially could not understand where he was coming from. In fact in many ways, he did my baseline ethos better than I did. If you look at books that serve the role of rQRH from a perspective of what they can do from a system perspective, they might be net negative because they inspire the very failed paradigm i have railed against in the past. While it was not my intent to create a roll of duct tape to fix a broken system of dedicating the right resources to ED resuscitation, the book may very well serve as just that. I edited the book from a place of optimism with the mindset of its use by true resuscitationists and perhaps to make situations better while waiting for help. But Joacim is correct, when looking at a book such as this from a more pessimistic perspective it may be a tiny little pontoon on a ship that should sink.

I still love the book and think it can help a ton of people and maybe that will trickle down to helping a few patients, but I see what Joacim is saying.

What do you think?

Let us know in the comments below. And if you think Joacim coming on the show to talk about creating systems of excellence, put that in the comments as well b/c he is on the fence.

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Cite this post as:

Scott Weingart. EMCrit – A Debate on the Use of Cognitive Decision Aids for Resuscitation and why Twitter is absolute, utter Crap. EMCrit Blog. Published on August 10, 2018. Accessed on January 21st 2019. Available at [http://emcrit.org/emcrit/emcrit-a-debate-on-the-use-of-cognitive-decision-aids-for-resuscitation-and-why-twitter-is-absolute-utter-crap/ ].

Financial Disclosures

Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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Giacomo Magagnotti

It seems to me that Joacim problem is more about Emergency Medicine trained physicians managing critical patients than about the book itself. However there also seem to be the implication that doctors with adeguate exposure and training should never need a quick referenze tool. I think we have been shown time and again that this belief is dangerous and can lead to tragedy….

I think the problem is there and there. Yes, cases do occur once in 10 years. And Yes, partial knowledge is a dangerous thing. But think saving a +1 life at 10 is really not enough? In addition, you need to understand that everything is interconnected – knowledge about one situation that happens every ten years – can help in 10 other situations. Of course, my words may sound stupid, I’m not a doctor, not a pilot, etc . But from the point of view of the human factor – so it is, the butterfly effect, one little thing can change everything. Don’t see the problem in this situation.

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jounalist

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5 months ago

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Jeff W

As a former airline pilot that practices medicine, I have a unique perspective and mixed feelings on this topic. I do not pretend to be a human factors expert or have all of the answers. I recently listened to Jim Afremow”s book ‘The Champion’s Mind’. In it he mentions that Michael Jordan has the NBA record for making the most game winning shots and the record for missing the most game winning shots. His shooting percentage for making game winning shots is below his career shooting percentage. Pressure degrades performance and if the GOAT falls victim, what do you think will happen to your performance? Don’t kid yourself because there has been multiple studies on the subject that indicate the same thing. Where medicine is going wrong with adopting checklists, QRH’s, etc is self induced and brought on by consultants. In my opinion, the biggest problem is too many administrative type go to the $99.95 Earl Scheib weekend course on bringing airplanes into the hospital and aren’t taught how all of it works in the airline industry. Partial knowledge can be dangerous. Any of you familiar with 14 CFR 91.3(b)? You should be because if you change pilot in command… Read more »

There will definitely be people who will cling to checklists as an excuse to be poorly versed in material, but I do not think those people should undermine the importance of checklists and cognitive aids. It seems to me the research is pretty clear checklists help even in medicine. Take the part-set cuing effect whereby recalling certain items items in a set can cause difficulty in recalling other items in that set. A checklist solves this problem by giving you all the items in the set ensuring you will not overlook any important task. That’s a cognitive bias that can affect even the best trained physicians. I look at checklists as a way to solve the problem of being human, not as a crutch to justify learning information poorly (or not at all).

Would view the RCM as fundamentally a set of checklists (augmented with additional details etc, but still fundamentally checklists). There are lots of folks out there who know far, far, far more about human factors research and checklists than I do, but that said here are a few thoughts: 1) Checklists for rarely encountered emergencies are unequivocally good. If we’re going to say that an intubation checklist is helpful (a situation which is commonly encountered), it is only logically coherent to say that a checklist for a rarely encountered emergency is vastly more important. This isn’t matter of training or intelligence, it’s about the fact that we are human beings who omit things when tired, stressed, hungry, and catecholamine-loaded. 2) Blindly following checklists like an idiot is bad. Fortunately, most docs aren’t idiots. The solution here is to avoid idiocy, not to avoid checklists. 3) Seeking expert advice is often wise, but also often logistically impossible (especially in a time-limited situation). 4) Tailored/personalized therapy is good, but it needs to start with an organized/structured approach to the problem and build upon that structure. 5) Intelligent discourse on twitter is possible (especially with 280 char limit). However, based on our emotional… Read more »

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intensivist

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5 months ago

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David Borshoff

After reading Joacim’s response, I was not going to be as generous as Scott (having been involved with cognitive aids for more than 20 years now) and was formulating my perspective on this before writing a response. However, I think your response, Josh, pretty well sums it up. When the Anaesthetic Crisis Manual was first published, there was a similar debate – particularly with the older, ego driven practitioners adopting the line of ‘not needing checklists’. However, simulation studies have since shown that many of us don’t perform as well as we imagine we would and that cognitive aids can be beneficial. I notice now that in the world of anaesthesia, most of the chatter has died down and people accept the benefits of cognitive aid support. In addition, I don’t think any intelligent. well educated and well trained doctor would use this book as a ‘recipe’ and treat by numbers. It is a manual of cognitive aids – that is how it is presented and how it should be used. Finally, regardless of what some people think, the younger generation of anaesthesiologists and dare I say now, resuscitationists, have made it very clear through the number of sales and… Read more »

Hey folks, I donˋt know if it’s good to discuss with the yodas of EM, but maybe every opinion counts in such a controversial debate. I don’t want to mess with you by telling how many intubations I did, because 1. it’s far far less than you all did and 2. it’s not of interest because me being part of EM is not worth a debate. Want to know why? Because if I, as a junior doc (5+years of EM) don’t do the job, no one else will… In most hospitals in germany juniors docs like me are responsible in the ED all night long with a consultant on call (15+ minutes ETA). Is this a good situation, no…is it reality…yes. Will it change? Not within the next ten years. Am I missing to call for help because of any damn book in my pocket…never ever. Will I always do my best to be prepared… I promise to. Will there be situations overwhelming me…definitely! Just stating that a system is crap and someone should not do a job is worthless… @mr Linde…if you wanna come to germany and change our system…I’ll be right on your 6 and back you up.… Read more »

LOL….so many haters out here. As a young and upcoming CritCare fellow, it’s quite funny to see so many old grumpy egotistical docs who are apparently BEYOND being helped by a book. Stop hatin’ – it will lower your own morbidity & mortality!

Very interesting debate !
It’s true that a big part of emergency medicine is not aim at resuscitation and i would have problem arguing that i am a better resuscitationist than a ICU guy managing exclusively sick patient at full time. I think that our main area of expertise is as chaos manager, we are the only area in medicine with absolutely no control on the type of patient that we need to care for. Doesn’t matter if you are working in a non trauma adult ED, you will have to manage the kid who get stabs on the street in front of your hospital or the pregnant patient in arrest .. And it’s surprising how little support you have in first hour of the vast majority of such cases. With such a wide variety of possible pathologies, it’s impossible to get enough exposure to develop a perfect approach to every situation. It’s exactly to bridge those gaps in my knowledge that i like cognitive aids with checklist.

I’m a paramedic so my frame is different. rQRH is a TOOL, nothing more & nothing less. No one knows everything at all times and under all conditions (e.g. times of cognitive overload). Having a checklist and/or reminder is not a bad idea. Forcing people to rely on memory, especially for rare incidents, is a recipe for stress & failure. [and we could start a whole thread on other problems like cognitive slip, etc.] Like all tools, it has the potential for good and for evil. Is it possiblethat some will use this in lieu of calling for assistance? Well, yeah, it’s possible but, as you said, that’s a bit of a strawman argument. But,even so, that possibility can be weighed against the value of the more likely greater number of people who will have this “in their back pocket” in case it’s needed and use it at the right time. My context? An ongoing debate as to whether paramedics should memorize all protocols and treatments. My answer: maybe to start with in order to establish a “mental map” for the student. Ultimately, however, few of us are running (for example) so many pediatric arrests that we’re going to 100%… Read more »

yes, rQRHs build the mental model that allows you to dispense with rQRH but even then you shouldn’t b/c it burns the mental model in even stronger each time you use it

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emcrit

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5 months ago

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Mark

The point here that I think Joacim is fundamentally making is essentially that even good protocols are no substitute for training. This is such an important principle, and one that I think is often critically underappreciated in modern healthcare. The scenario we all want to avoid is an ED which neglects to put the effort and money into training its clinicians, opting instead to keep a dusty copy of the manual on every nurses station – on paper certainly a much more cost effective solution. In the right context, however, there are many advantages to such a manual (though full disclosure, I’ve only read the sample protocol). 1. As a training aid. The manual is not a physiology textbook, and it’s not meant to be. It provides a concise summary of the clinical issues one might encounter with each presentation, and instructions on how to address them. For the “why”, you have to look somewhere else, but often Kumar and Clark isn’t the best place to look when you’re simply looking for practical advice of the angles from which to approach a patient. For a clinician encountering this for the first time (under the guidance of a senior), it can… Read more »

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Baby Gas Man

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5 months ago

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martin

What is being debated? This is a book. High quality and written by resus beasts. You can trust the information. If you know most of the content, you need it less; if you don’t, you should probably learn the material.

The debate ongoing here is ostensibly not about the book, but about the system and how to optimize care. How to train people and how to place docs in the right places. In that respect the discourse is healthy and welcomed.

BUT re: debate about books and twitter:

1. Books are good. Good books are sacred.
2. Dr Weingart as always is prob right. Twitter is a poor tool for discourse. Twitter is for linking to long reads, new articles, ECG pics, etc. Usually best to stay away from the devolving comment rabbit holes.

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academic EM doc in US

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martin

What is being debated? This is a book. High quality and written by resus beasts. You can trust the information. If you know most of the content, you need it less; if you don’t, you should probably learn the material.

The debate ongoing here is ostensibly not about the book, but about the system and how to optimize care. How to train people and how to place docs in the right places. In that respect the discourse is healthy and welcomed.

BUT re: debate about books and twitter:

1. Books are good. Good books are sacred.
2. Dr Weingart as always is prob right. Twitter is a poor tool for discourse. Twitter is for linking to long reads, new articles, ECG pics, etc. Usually best to stay away from the devolving comment rabbit holes.

As an off-the-cuff suggestion, maybe include this flowchart on page 1:

Are you the first point of contact? -> Yes -> Get help
|
No
|
Is this the first time you have managed this resuscitation event? -> Yes -> Get help
|
No
|
Is this a resuscitation event that you have specifically spent time learning to manage? -> No -> Get help
|
Yes
|
Are you the trained resuscitationist who has been tasked to attend this resuscitation event for the purpose of assisting with the management and disposition of the patient -> No -> Get help
|
Yes
|
Great. Thanks for coming. Would you like some help?
|
Crack on with the checklist.

Take care

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Critical care, Emergency medicine, Event medicine

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4 months ago

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Jon

Do you think this specific RCM would be beneficial to (at least some) Paramedics on the streets? Better yet, if you were their medical director, would you see the benefit? Surely a bit more than what we do, but perhaps gives us pause to think of the end game?

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3 months ago

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Stephen Gulland

Love this post .kudos to you both to engage in a spirited yet classy exchange of ideas and opposing views. P.s I agree with your views on twitter.

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Registered nurse, emergency

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5 months ago

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Per Bredmose

Hi, Great debate.. I think that both are right, and both debattants are showing mature behaviour in this debate – great ! I truly believe that there is a room for aid memoares.. however, these CAN NOT substitue or compensate for SKILLS, CLINICAL EXPOSURE (and experience) and KNOWLEDGE! My fear can be, with the Scandinavian frame ind the mindset, that such a checklist / booklet becomes the truth and the bible (as some cultures se the ie ATLS manual as)… it is extremely important to look at “frames”. I have only had the chance to read some of it, and there are parts that dont fit in to Scandinavian acute critical care best practise. Thats now it becomes difficult…. If a new speciality (with only limited clinical experience with critical illnes)(ie emergency medicine in some Scandinavian countries) adapt this book as the “bible” and the truth – and challenges the existing group that has a lifelong experience in care of acute critical ill… then the culture clash blooms…. Gentlemen, lets work for exceptional clinical care, tailored treatment for our patients. Lets face that we have diferent frames… This is similar to the checklist debate – the list that workd in… Read more »

there are many ways of accomplishing resus tasks and they will vary system to system based on resources, training, etc. But I don’t really think frame is the right lens to view these differences. Just as many base trainings go into Australian crit care making that specialty richer and more robust. WHat you are suggesting is very similar to the utterly dysfunctional system of USA critical care in which each specialty has their own crit care training, i.e. their own frame. This is a failure. There should only be 1 frame of resus-optimal care for the sickest patients. This will vary place to place b/c of the factors mentioned above, but not because of specialty or backgrounds. A surgically trained intensivist may take the pt to theatre themselves while a medically trained one may call a surgical colleague. the optimal care is the same.

there are many ways of accomplishing resus tasks and they will vary system to system based on resources, training, etc. But I don’t really think frame is the right lens to view these differences. Just as many base trainings go into Australian crit care making that specialty richer and more robust. WHat you are suggesting is very similar to the utterly dysfunctional system of USA critical care in which each specialty has their own crit care training, i.e. their own frame. This is a failure. There should only be 1 frame of resus-optimal care for the sickest patients. This will vary place to place b/c of the factors mentioned above, but not because of specialty or backgrounds. A surgically trained intensivist may take the pt to theatre themselves while a medically trained one may call a surgical colleague. the optimal care is the same.

loved and thoroughly agree with your smaccforce lecture, brother!

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emcrit

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5 months ago

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thomas fiero

all very interesting, both the main discourse, as well as the comments. i think it may be a very valuable experience to be honored with Dr Joacim Linde’s appearance on the show. I have the sense from his response that he has a good many other ideas about resus, and a great a many other aspects of health care delivery, education, philosophy. he is like a Swedish Scott Weingart, in a way. it may be tremendously educational and stimulating to see what Dr Linde perceives healthcare to be in his neck of the woods. i work in a shop that sees 72,000 patients a year, has no trauma surgeon, no stat cath lab, no peds service, no pulmonary/ICU/ intensivist. we ED docs are the anesthesiologists in the ER. in a very rural central valley. dr linde does not disallow that a patient , pregnant, stabbed, pedestrian vs truck, surgical neck airway, angioedema might be dropped off into our code room. ….. i am not sure even now (with the much more detailed discussion) that scott and joacim are “on the exact same page” as to the best plan to provide the best care for that patient. i know that joacim… Read more »

What's Your Job?

ed doc, merced california

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5 months ago

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thomas fiero

all very interesting, both the main discourse, as well as the comments. i think it may be a very valuable experience to be honored with Dr Joacim Linde’s appearance on the show. I have the sense from his response that he has a good many other ideas about resus, and a great a many other aspects of health care delivery, education, philosophy. he is like a Swedish Scott Weingart, in a way. it may be tremendously educational and stimulating to see what Dr Linde perceives healthcare to be in his neck of the woods. i work in a shop that sees 72,000 patients a year, has no trauma surgeon, no stat cath lab, no peds service, no pulmonary/ICU/ intensivist. we ED docs are the anesthesiologists in the ER. dr linde does not disallow that a patient , pregnant, stabbed, pedestrian vs truck, surgical neck airway, angioedema might be dropped off into our code room. ….. i am not sure even now (with the much more detailed discussion) that scott and joacim are “on the exact same page” as to the best plan to provide the best care for that patient. i know that joacim and scott would demand that i… Read more »

[…] Weingart has a fascinating reflective post on checklists, resuscitation, and the problems with Twitter as a medium for medical discourse. Definitely worth a read. A powerful reminder to think before judging someone’s comments. […]

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5 months ago

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Heather

I have enjoyed the discussions on EMCrit regarding checklist use. After being inspired by the podcast “Combat aviation paradigms for resuscitationists” two years ago and reading Atul Gawande’s The Checklist Manifesto: How to get things right, I wrote a paper for my master degree about why we should incorporate checklists into our care of patients in our department. I am trying to follow the link to buy the book, but I am unable to via https://resuscrisismanual.com. The “Buy now” just takes me to a basic html page on leeuwinpress.com. Is this book still available for print or in a digital format?